ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A client with congestive heart failure taking digoxin reports nausea and refuses to eat breakfast. Which action should the nurse take first?
- A. Encourage the client to eat the toast on the breakfast tray.
- B. Administer an antiemetic.
- C. Inform the client's provider.
- D. Check the client's apical pulse.
Correct answer: D
Rationale: The correct action for the nurse to take first is to check the client's apical pulse. Nausea can be a sign of digoxin toxicity, and one of the early signs of digoxin toxicity is changes in the pulse rate. By checking the client's apical pulse, the nurse can assess if the digoxin level is too high. Encouraging the client to eat or administering an antiemetic may not address the underlying issue of digoxin toxicity. While informing the provider is important, assessing the client's condition through checking the apical pulse should be the immediate priority.
2. A nurse is administering subcutaneous heparin to a client who is at risk for deep vein thrombosis. Which of the following actions should the nurse take?
- A. Administer the medication into the client's abdomen.
- B. Inject the medication into a muscle.
- C. Massage the site after administering the medication.
- D. Use a 22-gauge needle to administer the medication.
Correct answer: A
Rationale: Heparin is best absorbed and less likely to cause hematomas when administered into subcutaneous tissue, specifically the abdomen, which is a common site for subcutaneous injections. Injecting heparin into a muscle (Choice B) is incorrect as it should be administered subcutaneously. Massaging the site after administering the medication (Choice C) is contraindicated as it can cause tissue damage or bruising. Using a 22-gauge needle (Choice D) is not recommended for subcutaneous injections of heparin; a smaller needle size such as 25-26 gauge is preferred for subcutaneous administration.
3. A nurse is caring for an older adult client who has a new prescription for amitriptyline to treat depression. Which of the following diagnostic tests should the nurse plan to perform prior to starting the client on this medication?
- A. Hearing examination
- B. Glucose tolerance test
- C. Electrocardiogram
- D. Pulmonary function tests
Correct answer: C
Rationale: The correct answer is C: Electrocardiogram. Amitriptyline can cause cardiac arrhythmias, so an electrocardiogram is necessary before starting treatment. A hearing examination (choice A) is not required before initiating amitriptyline. A glucose tolerance test (choice B) is not indicated for starting this medication. Pulmonary function tests (choice D) are not necessary before initiating amitriptyline for depression.
4. A nurse is planning to administer epoetin alfa to a client who has chronic kidney failure. Which of the following data should the nurse plan to review prior to administration of this medication?
- A. Blood pressure
- B. Temperature
- C. Blood glucose levels
- D. Total protein levels
Correct answer: A
Rationale: The correct answer is A: Blood pressure. Epoetin alfa can increase blood pressure, especially in clients with chronic kidney failure. Monitoring blood pressure before administration is crucial to prevent hypertension. Reviewing temperature, blood glucose levels, or total protein levels is not directly related to the potential side effect of increased blood pressure associated with epoetin alfa.
5. A nurse is providing teaching to a client who has a urinary tract infection and new prescriptions for phenazopyridine and ciprofloxacin. Which of the following statements by the client indicates the need for further teaching?
- A. If the phenazopyridine upsets my stomach, I can take it with meals.
- B. The phenazopyridine will relieve my discomfort, but the ciprofloxacin will get rid of the infection.
- C. I need to drink 2 liters of fluid per day while I am taking the ciprofloxacin.
- D. I should notify my provider immediately if my urine turns an orange color.
Correct answer: D
Rationale: Phenazopyridine can turn the urine orange, which is a normal side effect and not a cause for alarm. The client's statement about notifying the provider immediately if their urine turns orange indicates a need for further teaching because it shows a misunderstanding of the medication's side effects. Choices A, B, and C demonstrate a good understanding of the prescribed medications and their effects, indicating the client has grasped the teaching provided on those aspects.